Modulation of doxorubicin sensitivity by cyclosporine A in hepatocellular carcinoma cells and their doxorubicin-resistant sublines

BACKGROUND AND AIMS

Cyclosporine A (Cys) and verapamil (Ver) sensitize multidrug-resistant (MDR) cells to various anticancer drugs by interacting with membrane glycoproteins involved in the drug efflux. In the present study, we assessed the effect of Cys on the modulation of doxorubicin (DOR) sensitivity in hepatocellular carcinoma (HCC) cell lines, and their DOR-resistant sublines.

METHODS

The sensitivity to DOR and the chemosensitizing effects of Cys were assessed by using two human HCC cell lines, PLC/PRF/5 and Hep-3B, and their DOR-resistant sublines, PLC/DOR and 3B/DOR. The expression of multidrug resistance 1 (MDR1) and multidrug resistance-associated protein (MRP) mRNA in these cells were detected by using a RT-PCR. The HCC cell lines grown in individual wells of 24-well plates were incubated with DOR that were sequentially diluted in culture medium in combination with 5 micromol/L Cys for 24 h. The cell viability in each well was measured by using a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay.

RESULTS

The mRNA of MDR1 and that of MRP were readily detectable in the HCC cell lines by RT-PCR. When 5 micromol/L Cys was added to the culture, the 50% inhibiting concentration (IC50) of DOR was reduced from 0.93 +/- 0.29 microg/mL to 0.32 +/- 0.10 microg/mL in PLC/PRF/5, and from 0.25 +/- 0.07 microg/mL to 0.09 +/- 0.04 microg/mL in Hep-3B. Furthermore, in the presence of 5 micromol/L Cys, the IC50 of DOR was reduced from 48.63 +/- 17.04 microg/mL to 0.49 +/- 0.14 microg/mL in PLC/DOR, and from 4.60 +/- 1.22 microg/mL to 0.15 +/- 0.06 microg/mL in 3B/DOR. The amounts of PCR products of MDR1 mRNA in PLC/DOR and 3B/DOR were greater than those in PLC/PRF/5 and Hep-3B, respectively.

CONCLUSIONS

In HCC, the amplification of MDR1 mRNA is probably the main mechanism underlying acquired DOR resistance. Cyclosporine is also indicated to be highly active in potentiating the anticancer activity of DOR in HCC cells and their DOR-resistant sublines.

Focal nodular hyperplasia coexistent with hemangioma and multiple cysts of the liver

We report here a case of hepatic focal nodular hyperplasia (FNH) associated with hepatic hemangioma and multiple hepatic cysts in a 71-year-old man. He was admitted to our hospital because of body weight loss. Ultrasonography detected multiple cysts. and two tumors in the liver one, 3.5 cm and one, 1.6 cm. Color Doppler ultrasonography showed arterial signals within the large tumor. On dynamic computed tomography, the large tumor was a hypodense lesion which was enhanced during the arterial phase and almost isodense during the delayed phase: the small tumor was also a hypodense lesion, and was enhanced during both the arterial and delayed phases. On magnetic resonance imaging using superparamagnetic iron oxides, the large tumor had decreased signal intensity on the T2-weighted image. On hepatic arteriography, the feeding artery of the large tumor showed a spoke-wheel appearance and that of the small tumor showed a cotton-wool appearance. Ultrasonographically guided fine-needle aspiration biopsy of the large tumor revealed hepatocellular hyperplasia. Finally, we diagnosed the two hepatic tumors as FNH and hemangioma. There was no intracranial lesion. The cause of the patient's emaciation was psychogenic anorexia. To our knowledge, this is the first case report that describes the simultaneous occurrence of these three kinds of hepatic lesions. The pathogenesis of FNH still remains unclear, but this association suggests that FNH may arise because of a vascular anomaly.

Increase in CD95 (Fas/APO-1)-positive CD4+ and CD8+ T cells in peripheral blood derived from patients with autoimmune hepatitis or chronic hepatitis C with autoimmune phenomena

BACKGROUND

The expressions of CD95 (Fas/APO-1) and Bcl-2 are determinants of apoptosis in normal lymphocytes, and abnormalities in their expressions might contribute to the induction of autoimmunity. In this study, we examined the expressions of CD95 and Bcl-2 on freshly isolated T and B cells from patients with autoimmune hepatitis (AIH) or chronic hepatitis C associated with autoimmune phenomena (CH-C(AI)).

METHODS

The CD95 and Bcl-2 expressions within CD4+ T, CD8+ T, and CD19+ B cell subsets were analysed by two-colour flow cytometry.

RESULTS

The surface expression of CD95 was significantly high in both the CD4+ T and CD8+ T cell subsets derived from the patients with AIH and those with CH-C(AI), compared with expression in patients with CH-C and normal subjects. The increase in CD95 expression was associated with the phenotypic conversion of naive CD45RO- to primed CD45RO+ CD4+ T cells. Bcl-2 was detected in the vast majority of peripheral T and B cells. There was no significant difference in the percentage of Bcl-2-positive cells in the CD4+ T cell, CD8+ T cell and CD19+ B cell subsets among the patient groups and normal subjects.

CONCLUSIONS

These results indicate that an increase in CD4+ T cells expressing CD45RO and CD95 marks an important subset of AIH and CH-C(AI) patients. These expanded CD95+ CD45RO+ primed T cells most likely reflect a continuous antigen-specific or non-specific activation of T lymphocytes, and/or the persistent presence of activated lymphocytes as a consequence of abnormalities in the peripheral deletion of activated lymphocytes. These persistently activated lymphocytes might play a role in the induction of autoimmunity in AIH and CH-C(AI).

Association of chronic infection of Chlamydia pneumoniae and coronary heart disease in the Japanese

The association of Chlamydia pneumoniae with atherosclerosis of coronary and carotid arteries and the aorta has been demonstrated by seroepidemiology and by detection of the organism in atheromata. We investigated the frequency of C. pneumoniae seropositivity in patients with acute myocardial infarction (AMI). C. pneumoniae-specific antibodies were measured by the microimmunofluorescence test in 160 AMI patients and 160 control subjects matched for age and gender. The odds ratios (ORs) were 2.2 (95% confidence interval (CI), 1.2 to 3.9) for immunoglobulin (Ig)G and 2.7 (95% CI, 1.7 to 4.3) for IgA. After adjustment for other cardiovascular risk factors of age, gender, hypertension, diabetes, cigarette smoking and serum cholesterol, the ORs were essentially unchanged. This study confirmed that the observations of an association between antibody against C. pneumoniae and coronary heart disease in Western nations is also present in Japan. Our results are comparable to the previous seroepidemiological studies reporting ORs of 2.0 or greater.

[Mechanism and clinical usefulness of S4-S1 interval in heart failure associated with left ventricular inflow pattern]

The interval between S4 and S1 detected by auscultation or phonocardiography is prolonged by exacerbation and shortened by improvement of heart failure. The timing of S4, S1, and the terminal point of the A wave of transmitral inflow velocities on pulsed Doppler echocardiography (At) was studied to elucidate the mechanism of the prolongation of the S4-S1 interval on exacerbation of heart failure. The study population consisted of 30 patients, nine with old myocardial infarction, six with dilated cardiomyopathy, six with hypertensive heart disease, nine with chronic hemodialysis, and 17 normal subjects. The interval from the peak of the A wave by apexcardiography and At to the onset of main vibration of S1 were measured as the S4-S1 interval and At-S1 interval, respectively. The P-Q interval and Q-S1 interval were also measured. Both intervals were compared during exacerbation and improvement of heart failure. Patients with P-Q prolongation were excluded. The S4-S1 interval was 102 +/- 24 msec during exacerbation of heart failure or before hemodialysis, and shortened to 76 +/- 18 msec after improvement of heart failure or after hemodialysis. The At-S1 interval was concordantly shortened from 59 +/- 31 msec to 30 +/- 23 msec (p < 0.001). However, both the P-Q interval and Q-S1 interval were not significantly changed before and after improvement of heart failure. The timing of S4 becomes parallel to that of At earlier during the exacerbation of heart failure. Thus, S4-S1 interval is a convenient and useful index to investigate patients with heart failure.

Genomic organization and mutational analysis of HERG, a gene responsible for familial long QT syndrome

Familial long QT syndrome (LQTS) is characterized by prolonged ventricular repolarization. Clinical symptoms include recurrent syncopal attacks, and sudden death may occur as a result of ventricular tachyarrhythmias. Three genes responsible for this syndrome (KVLQT1, HERG, and SCN5A) have been identified so far, and mutations have been reported on the basis of partially characterized genomic organization. To optimize the search for HERG mutations, we have determined the genomic structure of HERG and investigated mutations in LQTS families. Human genomic clones containing the HERG gene were isolated from a human genomic library by using reverse-transcribed polymerase chain reaction (RT-PCR) products from this gene as probes. We determined exon/intron boundaries and flanking intronic sequences by using primers synthesized on the basis of the HERG cDNA sequence available in the DNA database. HERG was shown to consist of 15 exons spanning approximately 19 kb on chromosome 7q35. Subsequently, we synthesized oligonucleotide primers to cover the entire coding region and searched for mutations in 36 Japanese LQTS families. When genomic DNA from each proband was examined by the PCR/single-strand conformation polymorphism technique followed by direct DNA sequencing, five novel mutations were detected. Each mutation was present in affected relatives of the respective proband. This work should increase the efficiency of screening mutations associated with HERG.

[Estimation of left ventricular systolic function based on the electrocardiograms in cases with left bundle branch block]

The electrocardiographic features indicating left ventricular dysfunction were studied in 32 consecutive patients having left bundle branch block including 10 with idiopathic genesis without significant underlying disease, 6 with dilated cardiomyopathy, 8 with old myocardial infarction, and 8 with hypertensive heart disease. The patients were divided into two groups; those with favorable left ventricular systolic function and those with poor left ventricular systolic function evaluated by using non-invasive methods. Electrocardiographic findings were compared between these two groups. Ten patients had favorable and 22 poor left ventricular systolic function. One or more of the following electrocardiographic findings were observed in the poor group, but none in the favorable group: low voltage in the limb leads, prolonged intraventricular conduction (QRS duration wider than 0.17 sec), transitional zone between V5 and V6, depression of the ST-J point by more than 0.2 mV in V6, reverse progression of the R wave in V1-V5, marked left axis deviation (axis beyond: 30 degrees), left atrial overload (positive Morris index), PQ prolongation, and abnormal Q waves in I, aVL, V6. No significant differences in the distribution of these findings was observed in any of the underlying diseases. The clinical background of patients with left bundle branch block who had no significant underlying disease showed favorable left ventricular systolic function except the patients above 80 years of age, who showed poor left ventricular systolic function. In contrast, patients with underlying mild hypertensive heart disease may have a favorable left ventricular systolic function. Thus, left ventricular systolic function in patients with left bundle branch block may be suspected by observing these electrocardiographic findings.

Electrocardiographic features differentiating dilated cardiomyopathy from hypertrophic cardiomyopathy

To determine the usefulness of electrocardiographic (ECG) features in differentiating between hypertrophic cardiomyopathy with features mimicking dilated cardiomyopathy (D-HCM) and true dilated cardiomyopathy (DCM), we compared ECGs of 52 consecutive patients (11 with D-HCM, 41 with DCM). Left atrial dimension, left ventricular internal dimension, and septal and posterior wall thickness were employed as echocardiographic indexes, while QRS duration, amplitude of RV5 or V6 + SV1, number of abnormal Q waves, P-terminal force in V1, and frontal plane QRS axis were used as ECG parameters. The patients with D-HCM demonstrated a larger number of abnormal Q waves (P < .0001), greater prolongation of QRS duration (P < .0001), and lower amplitude of RV5 or V6 + SV1 (P < .0001). In all cases of D-HCM, atrial overload was observed and abnormal QRS axis in 9 (82%) of the 11 patients. These features were noted in 21 (51%) and 17 (41%), respectively, of the 41 DCM patients (P < .005 and P < .05, respectively). Despite significant differences in the echocardiographic parameters between D-HCM and DCM, excluding left ventricular end-diastolic dimension, ECG abnormalities were more significant between the two groups. The results indicate that ECG features are extremely useful in differentiation between DCM and D-HCM.

Four novel KVLQT1 and four novel HERG mutations in familial long-QT syndrome

BACKGROUND

Familial long-QT syndrome (LQTS) is characterized by prolonged ventricular repolarization. Clinical symptoms include recurrent syncopal attacks, and sudden death may occur due to ventricular tachyarrhythmias. Three genes responsible for this syndrome (KVLQT1, HERG, and SCN5A) have been identified so far. We investigated mutations of these genes in LQTS families.

METHODS AND RESULTS

Thirty-two Japanese families with LQTS were brought together for screening for mutations. Genomic DNA from each proband was examined by the polymerase chain reaction-single-strand conformation polymorphism technique followed by direct DNA sequencing. In four of the families, comprising 16 patients, mutations were identified in KVLQT1; five other families (9 patients) segregated mutant alleles of HERG. All 25 of these patients carried the specific mutations present in their respective families, and none of 80 normal individuals carried these alleles. Mutations were confirmed by endonuclease digestion or hybridization of mutant allele-specific oligonucleotides. No mutation in SCN5A was found in any family.

CONCLUSIONS

We identified nine different mutations among 32 families with LQTS. Eight of these were novel and account for 25% of all types of mutations reported to date. Such a variety of mutations makes it difficult to screen high-risk groups using simple methods such as endonuclease digestion or mutant allele-specific amplification.

Clinical significance of abnormal postexercise systolic blood pressure response in patients with hypertrophic cardiomyopathy

The clinical significance of abnormal postexercise systolic blood pressure (SBP) response in patients with hypertrophic cardiomyopathy (HCM) was assessed by treadmill exercise testing in 30 normal subjects and 96 patients with HCM. SBP recovery ratios were derived by dividing the SBP at 1 and 3 min after exercise by the peak exercise SBP. The upper normal limit of the SBP ratio was defined by two standard deviations (SD) from the mean in 30 normal subjects. A postexercise SBP ratio that exceeded the upper normal limits of the SBP ratio was considered to be an abnormal SBP response in patients with HCM. Twenty-seven (28%) of 96 patients with HCM showed an abnormal SBP response. Compared with the normal SBP response group (69 cases) among patients with HCM, the abnormal SBP response group had lower SBP response during exercise (22 +/- 25 vs 62 +/- 26 mmHg : mean +/- 1 SD, p < 0.05), more prolonged QRS width (110 +/- 21 vs 92 +/- 20 msec, p < 0.05), higher incidences of ventricular tachycardia (12 vs 7 cases, p < 0.001), and sudden death (7 vs 0 cases, p < 0.0001). The defect area of Tl-201 myocardial scintigraphy was more extensive in the abnormal SBP response group (2.9 +/- 1.7 segments) than in the normal SBP response group (1.1 +/- 1.3 segments, p < 0.05). During atrial pacing (120/min), pulmonary artery wedge pressure was slightly elevated from 10 +/- 2 (at rest) to 14 +/- 3 mmHg (during pacing) (p<0.001), cardiac index showed no significant changes, and time constant T was shortened from 58 +/- 13 to 48 +/- 10 msec (p < 0.001) in the normal SBP response group, but in the abnormal SBP response group pulmonary artery wedge pressure was highly elevated from 12 +/- 5 to 20 +/- 3 mmHg (p < 0.0001), cardiac index was decreased from 2.5 +/- 0.7 to 2.1 +/- 0.6 l/min/m2 (p < 0.05), and the time constant T had no significant changes. These observations suggest that patients with HCM and abnormal postexercise SBP response have an abnormal cardiac response during exercise and extensive myocardial damage.

[Prognostic importance of pseudonormalized left ventricular inflow pattern especially for sudden cardiac death]

The prognostic value of left ventricular inflow velocities by the pulsed Doppler method was studied in 32 patients with congestive heart failure including 18 with old myocardial infarction, 9 with dilated cardiomyopathy, and 5 with hypertensive heart disease, who initially revealed pseudonormalized left ventricular inflow pattern. Pulsed Doppler echocardiography, apexcardiography, and phonocardiography were performed at 3- to 9-month intervals. The prognosis was evaluated for two groups of patients with persistent or transient pseudonormalized inflow patterns. Survival rates at 6 months and 2 years in the total patient population were 78% and 47%, respectively. Twenty-one patients had the pseudonormalized left ventricular inflow pattern (persistent group), while the other 11 patients had a changed pattern (transient group). The survival rate at 2 years was 37% for the persistent group, and 82% for the transient group. Significant differences in patient profiles and the initial data between the two patient groups were the presence of cardiogenic shock (10/21 in persistent group vs 1/11 in transient group; p < 0.001) and the value of left ventricular end-diastolic wall stress (159 +/- 62 g/cm2 in persistent group vs 135 +/- 42 g/cm2 in transient group; p < 0.05). There were no significant differences in NYHA class, the values of left ventricular end-diastolic pressure, left ventricular ejection fraction. A/E ratio, or deceleration half time of left ventricular inflow velocities. Left ventricular end-diastolic wall stress in patients with persistent pseudonormalized left ventricular inflow pattern was significantly increased, and may be related to decreased preload reserve. Atrial fibrillation and atrioventricular dissociation were recorded prior to the development of ventricular fibrillation in two patients with sudden cardiac death. Abrupt loss of atrial contribution as well as ventricular arrhythmias may be a trigger of sudden death. Evaluation and follow-up of the pseudonormalized left ventricular inflow pattern is a sensitive indicator for the management of patients with congestive heart failure.

[Early diagnosis and management of acute pulmonary embolism: clinical evaluation those of 225 cases]

To contribute for making early diagnosis and treatment of acute pulmonary embolism (APE), we investigated on clinical pictures of 225 patients with APE. Common underlying factors were heart disease, prolonged bed rest, post-surgical state, thrombophlebitis, malignant tumor and post-catheterization state in this order. Dyspnea, chest pain, tachycardia and shock were frequently seen as initial symptoms and signs. Blood screening showed leukocytosis, hypoxemia, hypocapnia and elevated serum LDH. Electrocardiographic findings highly demonstrated were ST.T abnormalities, such as T inversion with ST elevation in V1-3, ST depression in V4-6 and sinus tachycardia. Chest X-rays showed diminished pulmonary vascular marking and pulmonary artery dilation. Right ventricular dilatation were frequently seen on 2-dimensional echocardiograms. Pulmonary artery pressure were elevated up to 49/20 (30) mmHg. Twenty-five percent of the patients died, and the recurrence was seen in 4%. Thus, as soon as APE is suspected by above clinical findings, definitive diagnosis should be obtained by the lung perfusion scan and pulmonary arteriography, then oxygen and thrombolytic agents should be given immediately to prevent the fatal outcome.

Decreased mid-to-late diastolic decay of diastolic coronary artery flow velocity in pressure-overloaded left ventricular hypertrophy

This study was carried out to investigate the characteristics of coronary arterial flow in left ventricular hypertrophy secondary to systemic hypertension. The blood velocities in the left anterior descending coronary artery (LAD) were measured by a No. 3F 20 MHz Doppler catheter in 23 hypertensive patients with left ventricular hypertrophy (systolic/diastolic pressure: 181 +/- 15/100 +/- 4 mmHg) and 13 patients with atypical chest pain, but without left ventricular hypertrophy and any abnormal hemodynamic findings. All patients had normal coronary arteriograms. The LAD blood velocity waveforms in pressure overloaded left ventricular hypertrophy were characterized by both a decreased mid-to-late diastolic deceleration rate (delta V/delta T) and a normalized value of delta V/delta T by peak diastolic velocity [delta V/(delta T.Vpeak)], as well as delayed early diastolic inflow (time for diastolic rise; TDR). The values of the delta V/(delta T.Vpeak) in the patients with hypertensive left ventricular hypertrophy and in the normotensive controls were 1.26 +/- 0.61 and 3.03 +/- 1.18/s, respectively (P < 0.001). The TDR was 145 +/- 56 and 66 +/- 15 ms (P < 0.001). In patients with hypertensive left ventricular hypertrophy, the delta V/(delta T.Vpeak) correlated well with the degree of hypertrophy (r = 0.75, P < 0.01) and with the TDR (r = 0.82, P < 0.01). The coronary flow reserve, calculated from the ratio of the diastolic mean velocity after intracoronary injection of papaverine to the resting flow velocity increased with the delta V/(delta T.Vpeak) (r = 0.68, P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Mechanism of discrepancy between mean pulmonary capillary wedge pressure and left ventricular end-diastolic pressure]

It is well known that discrepancies between mean pulmonary capillary wedge pressure (man-PCWP) and left ventricular end-diastolic pressure (LVEDP) exist in the pathological heart with sinus rhythm. We discussed the mechanism of these discrepancies in the aspect of increased LV end-diastolic stiffness. Fifty-two patients observed in this study included 23 with old myocardial infarction (OMI), 4 with hypertrophic cardiomyopathy and 9 with hypertensive heart disease (LVH group), 6 with dilated cardiomyopathy (DCM), and 10 normal subjects (N). All 52 patients had sinus rhythm. Those with significant mitral and aortic regurgitation were excluded. End-diastolic LV stiffness was evaluated by the ratio of increases in LV pressure and volume during atrial systole (delta P/delta V), as proved by cardiac catheterization and cine-angiography. Discrepancies between m-PCWP and LVEDP were 5.9 +/- 4.3 mmHg in OMI group, 4.5 +/- 4.6 mmHg in LVH group, 5.8 +/- 4.5 mmHg in DCM, and 1.6 +/- 1.8 mmHg in N group. These discrepancies correlated well with delta P/delta V (r = 0.74). More significant discrepancies were observed in patients with so-called pseudo-normalized left ventricular inflow velocities proved by pulsed Doppler echocardiography, and in patients with marked concentric LV hypertrophy with increased delta P/delta V. In clinical observation, symptoms of heart failure may be determined by m-PCWP rather than LVEDP. We concluded that discrepancies between m-PCWP and LVEDP were caused by the booster pump function of the left atrium against increased LV end-diastolic stiffness. By the use of apexcardiogram and echocardiogram including the pulsed Doppler method, it was possible to predict these discrepancies non-invasively.

[Autonomic function and severity of hypertrophic cardiomyopathy by power spectrum analysis on heart rate variability]

To examine the relation of autonomic function and severity of hypertrophic cardiomyopathy (HCM) with and without ventricular tachycardia (VT) and poor blood pressure response on Treadmill exercise, 30 patients with HCM and 10 healthy controls were selected. Autonomic function was assessed by heart rate variability (HRV) on 24hr-Holter monitoring. The power spectrum analysis was classified into LF component, HF component and ratio of LF/HF. (1) Night time HF and LF decreased, and LF/HF increased in HCM compared with healthy controls. (2) HF decreased more in HCM with VT. (3) LF/HF also decreased in HCM with poor blood pressure response on exercise. These results suggest that autonomic function may be altered in HCM, and severity of HCM proved to be able to be assessed by power spectrum analysis of HRV.

[Long-term follow-up of clinical features and ECG changes in 50 patients with HCM]

We studied the relation of ECG changes during the clinical course in patients with hypertrophic cardiomyopathy (HCM). Fifty patients with HCM were categorized in two groups; 20 patients with, and 30 patients without signs of deterioration of clinical state. The changes between the first and the final ECG were compared in these two groups. The average follow-up period was 7.6 years. Twenty patients with clinical deterioration presented increase in QRS intervals (0.06----0.071 sec, p less than 0.025), decrease in voltage of RV5 (2.81----2.38 sec, p less than 0.025), increase in newly developed abnormal Q waves, and P wave changes. In contrast to these cases, 30 patients without clinical deterioration presented no significant ECG changes. Amplitudes of the negative T wave were unchanged in both groups. We conclude that electrocardiographic observations proved to be useful for predicting clinical features in patients with HCM.

A novel class of enkephalinase inhibitors containing a C-terminal sulfo group

A new series of sulfonic acids were synthesized and tested for their enkephalinase inhibitory activity. Among them, the most potent was N-(2-benzyl-3-mercaptopropionyl)metanilic acid 10i with an IC50 value of 0.27 nM. Several other analogues (10a,b,j,n,o,gg,hh) showed the inhibitory activity comparable to or greater than thiorphan (IC50 = 2.6 nM), a C-terminal carboxyl-containing inhibitor of enkephalinase. Thus compounds containing a C-terminal sulfo group, instead of the C-terminal carboxyl group, were found to show a remarkably high level of inhibition of enkephalinase. The analgesic activity of 10b, (S)-10b, and (R)-10b was also evaluated by the phenylbenzoquinone writhing test.

[Effect of heart rate on cardiac hemodynamics in patients with aortic regurgitation]

We evaluated the effects of heart rate on cardiac hemodynamics in 10 patients with aortic regurgitation (AR, mean regurgitant fraction: 64.3%). Cardiac catheterization was performed in all patients, and the hemodynamic parameters were obtained by increasing heart rate (80.100.120.140) using right atrial pacing. Regurgitant fraction and total systemic resistance were improved up to 100/min, but aggravated on further increase in heart rate. Cardiac function curve was remarkably improved up to 100/min, but aggravated on further increase in heart rate. LV end-diastolic pressure-volume relation was moved toward the left lower direction up to 100/min, but toward the left upper direction on further increase in heart rate. Thus, it was concluded that in severe AR, cardiac function was improved up to 100/min, but aggravated on further increase in heart rate.

Effect of left ventricular hypertrophy secondary to systemic hypertension on left coronary artery flow dynamics

STUDY OBJECTIVE

The aim was to clarify the characteristics of the phasic blood velocity pattern and their possible causes in left ventricular hypertrophy secondary to systemic hypertension.

DESIGN

Measurements of blood velocities in the left anterior descending coronary artery were made with a 20 MHz Doppler catheter with a top mounted annular crystal. All patients had normal coronary arteriograms.

PATIENTS

23 hypertensive patients [systolic/diastolic pressure: 181(SD 15)/100(4) mm Hg)] with left ventricular hypertrophy, and 13 atypical chest pain patients without left ventricular hypertrophy or any abnormal haemodynamic findings (normal controls) entered the study.

MEASUREMENTS AND MAIN RESULTS

The left anterior descending coronary artery blood velocity waveform in pressure overloaded left ventricular hypertrophy was characterised by delayed early diastolic inflow. The diastolic rise time of coronary flow (TDR), ie, the time from the beginning of diastole to peak velocity, was higher in patients with hypertensive left ventricular hypertrophy than in normal controls, at 145(56) v 66(15) ms, p less than 0.001. In patients with hypertensive left ventricular hypertrophy, TDR correlated well with the degree of hypertrophy (r = 0.83, p less than 0.01) and also with peak left ventricular systolic pressure (r = 0.62, p less than 0.01). The coronary flow reserve, calculated from the ratio of the diastolic mean velocity after intracoronary injection of papaverine to the resting flow velocity, decreased with prolongation of TDR (r = 0.58, p less than 0.02).

CONCLUSIONS

(1) Impairment of early diastolic coronary arterial inflow is the most remarkable characteristic in pressure overloaded left ventricular hypertrophy; (2) preceding systolic vascular compression and impaired left ventricular relaxation correlate with the delayed early diastolic inflow; (3) the delayed inflow is an important possible cause of the decreased coronary flow reserve in the hypertensive left ventricular hypertrophy.

[Exercise induced precordial T wave normalization associated with U wave inversion in detection of left anterior descending artery stenosis]

Although normalization of inverted T wave is not an uncommon finding during exercise tests, it's clinical significance is still unclear. Exercise 12-lead electrocardiograms (ECGs) were recorded by using Master's 2-step or ergometer. T wave normalization in the anterior chest leads was found in 20 patients with, and 14 patients without coronary artery disease (CAD). Coronary angiography and/or exercise Tl-201 myocardial imaging were also performed in every patient. Exercise-induced T wave normalization was defined as "inverted T wave at rest becoming upright during exercise". ST segment, T and U wave amplitudes were measured before and immediately after exercise. 1) All of the 20 patients (100%) with CAD demonstrated critical stenosis of the left anterior descending artery (LAD). 2) ST deviation was noted in none of the 14 patients (0%) without CAD, and in only 4 of the 20 patients (20%) with CAD. 3) T wave amplitude increased equally in patients both with and without CAD. 4) Exercise-induced U wave inversion was found in 16 of the 20 patients (80%) with CAD, whereas it was found in only 1 of the 14 patients (7%) without CAD. 5) The sensitivity of "U wave inversion" in detection of LAD stenosis was 80%, and the specificity was 93%. We conclude that exercise-induced T wave normalization associated with U wave inversion in anterior chest leads is highly indicative of the specific presence of critical LAD stenosis.

[Treadmill exercise test in patients with hypertrophic cardiomyopathy with and without coronary artery disease]

We studied whether the treadmill exercise test can discriminate between normal and significant narrowing of coronary arteries in patients with hypertrophic cardiomyopathy (HCM) accompanied with chest pain, and we compared the extent of myocardial ischemia during exercise. Thirty one patients with HCM were divided into two groups; 21 with normal coronary arteries and 11 with significant narrowing of coronary arteries. The treadmill exercise test was carried out in both groups. The following parameters were more frequently seen in the group with coronary stenosis. (1) short treadmill time (338, sec vs 542, p less than 0.05). (2) delta SBP less than or equal to 60 mmHg (delta: end point minus rest, 10 cases vs 12, 0.05 less than p less than 0.1). (3) significant delta ST depression (0.17 mV vs 0.05, p less than 0.05). (4) large delta ST/delta HR (3.3 microV.min/beats vs 0.7). delta ST/delta HR greater than or equal to 2.0 was the most useful for differentiating the two groups, and it was 90% in index both sensitivity and specificity for diagnosis of HCM with significant narrowing of the coronary arteries. It was concluded that treadmill exercise induced more severe myocardial ischemia in patients with HCM who had significant narrowing of the coronary arteries than in patients with HCM who had angiographically normal coronary arteries. The delta ST/delta HR was the most useful index for diagnosis of HCM with significant narrowing of the coronary arteries.

[Usefulness for evaluation of the left ventricular disorders by apexcardiographic A-wave ratio in patients with hypertrophic cardiomyopathy]

Usefulness for evaluation of left ventricular disorders by apexcardiographic A-wave ratio was studied in 48 patients with hypertrophic cardiomyopathy. These subjects were divided into 3 groups: A-wave ratio less than or equal to 15% (group 1), 16% less than or equal to A-wave ratio less than or equal to 29% (group 2), and A-wave ratio greater than or equal to 30% (group 3). A-wave ratio was found to have a positive correlation with Time constant T (r = + 0.71), left ventricular end-diastolic pressure (r = +0.46), and left ventricular atrial kick (r = +0.55). During exercise, ejection fraction decreased significantly (p less than 0.05) in group 3 as compared to group 1. During treadmill exercise test, rise of systolic blood pressure was significantly (p less than 0.05) poor, and there was a large number of ST depression (p less than 0.05) in group 3. It was recognized by exercise thallium-201 myocardial scintigraphy, that the frequency of perfusion defect was 30% in group 3. In conclusion, high A-wave ratio may strongly suggest impaired left ventricular diastolic function, and, there was correlated to abnormal hemodynamic state during exercise. Apexcardiographic A-wave ratio proved to be useful in patients with hypertrophic cardiomyopathy. It is useful for evaluation of left ventricular disorders.

[A case of silent posterior myocardial ischemia/left circumflex artery obstruction detected by prominent U-wave in right precordial leads]

A 64-year-old woman with a history of hypertension for ten years and of syncope 18 month previously visited our Division of Cardiology on 12 June, 1989. The S4 and mitral regurgitation were audible at the apex, and her electrocardiogram showed ST-depression in leads II, aVF, V5-6 and prominent U-wave (PU) in V1-3 when first seen. Then, she was thought to have a posterior myocardial ischemia. PU in V1-3 diminished whereas T-wave increased after nitrate and Ca++ blocker. Ergometer exercise ECG showed ST-depression in II, III, aVF, V4-6 and PU with decreased T-wave in V2-3 with no apparent symptoms. Simultaneously, Tl-201 myocardial imaging demonstrated a transient posterior defect. A silent posterior myocardial ischemia was, therefore, confirmed. Coronary arteriograms demonstrated subtotal obstruction of the proximal left circumflex artery, and the peripheral site was filled by collaterals from the right coronary artery. Angina-induced PU in the right precordial leads proved to be useful in detection of posterior myocardial ischemia, and this marker may also improve the possibility of detection of silent posterior ischemia.

[A case of acute pericarditis secondary to mediastinitis]

A 45-year-old man who complained of swallowing disturbance and chest pain in inspiration phase was admitted for evaluation of "pericarditis". A chest X-ray film on admission disclosed a wide mediastinal shadow and pleural effusion on the right side. Bilateral tonsils were swollen, and covered with pus. A Computed tomogram of the chest showed a shadow of exudate contained with air in the mediastinum. Mediastinal drainage, tonsillectomy and drainage of fistula from pre-tracheal space to upper mediastinum were immediately performed. Staphylococcus aureus was confirmed from the sputum and mediastinal effusion. Thus, acute mediastinitis was confirmed as an etiological diagnosis of "pericarditis" in this patient.

[Right pulmonary artery obstruction and pulmonary hypertension secondary to aortitis syndrome]

A 56-year-old woman with aortic arch syndrome and finally right pulmonary artery obstruction secondary to Takayasu's aortitis was presented. She had had a history of visual disturbance and dizziness when she looked upward since 1983. On admission in July, 1984, aortography showed obstruction of the right innominate artery and of the left subclavian artery. Pulmonary arterial pressure, pulmonary perfusion and ventilation images seemed to be normal at that time. After discharge from our hospital, she began in 1987, to be aware of dyspnea on effort. Because of this symptom, she was admitted again in March, 1988. The pulmonary perfusion images showed complete lack of perfusion in the right lung, and arterial blood gas showed hypoxia with 62 mmHg in PaO2, 39 mmHg in PaCO2. Cardiac catheterization confirmed pulmonary hypertension with pulmonary artery pressure of 56/18 mmHg. In conclusion, pulmonary perfusion and ventilation scintigraphy proved to be the best way to clarify the nature of a lesion of the pulmonary artery in aortitis syndrome.

Spectrum of restrictive cardiomyopathy: report of the national survey in Japan

This report describes clinical profiles and echocardiographic, hemodynamic, and histologic findings in 26 cases of idiopathic RCM based on the diagnostic criteria of (1) heart failure resulting from a stiff left ventricle, (2) normal LV size and systolic function, (3) absence of LV hypertrophy, and (4) cause or association unknown. There were 14 male and 12 female patients ranging in age from 5 to 63 years. Ten patients died during the mean follow-up period of 145 months, and five died of heart failure after 10 years. Three had a family history of HCM. Thromboembolism was observed in eight. Echocardiograms showed normal LV wall thickness and contraction. Hemodynamic characteristics included elevated biventricular filling pressures and a pulmonary wedge pressure that was usually higher than the right atrial pressure. Equalization of biventricular filling pressures was seen, however, in almost all patients with severe tricuspid regurgitation (seven of eight). The square root sign was seen in 50% in RV diastolic pressure tracings and 28% in LV tracings. This sign was observed in patients with elevated filling pressures. Interstitial fibrosis (22 of 23), endocardial thickening (13 of 23), and myofibrillar hypertrophy (10 of 23) were common histologic findings. Severe myocardial fiber disarray consistent with HCM was seen in four patients.

Accuracy of 20-MHz Doppler catheter coronary artery velocimetry for measurement of coronary blood flow velocity

The accuracy of 20-MHz Doppler catheter coronary artery velocimetry (Millar Instruments) was evaluated by model experiments using a turntable and a flow tube. In the turntable experiments, the flow away from the catheter tip (away flow) was significantly lower than that toward the catheter (toward flow), but the measured velocities for both away and toward flows were always lower than the known velocities. Nevertheless, the blood velocities measured at a sampling point 4 mm from the catheter tip showed excellent correlation with the known velocities irrespective of flow direction. The shape of the FFT spectra of the Doppler shift frequency from blood was broadened, and the frequency corresponding to the known velocity was always close to the maximum Doppler shift frequency. We concluded that zero-cross detection of blood velocity by the 20-MHz pulsed Doppler catheter provides a reliable measure for evaluating relative velocity changes, although it underestimates the blood velocity.

[Two cases of primary artery dissection]

We experienced two cases of primary coronary artery dissection. (Case 1) 55-year-old man had frequent episodes of chest oppression at early morning and midnight. During chest oppression, electrocardiogram showed transient ST-segment elevation in leads II, III, and a VF. Then, he was diagnosed as having angina pectoris. This diagnosis was based on the fact that he presented coronary spastic syndrome. Right coronary angiogram demonstrated an intimal flap and false lumen at segment 3, and primary coronary dissection was confirmed. (Case 2) A 27-year-old woman complained of back pain while taking a bath. Electrocardiogram showed ST-segment elevation and abnormal Q in leads V2, V3 and V4. She was diagnosed as having acute anterior wall myocardial infarction. Presence of coronary artery dissection at segment 6 was identified by left coronary angiogram. Primary coronary artery dissection is clinically diagnosed by coronary angiogram very rarely. Only 27 such cases have been reported. It was speculated that, in case 1, vasospastic angina may be associated with primary coronary artery dissection. Case 2 had primary coronary artery dissection at segment 6 of the left anterior descending artery. Thus, her clinical picture was similar to those of previously reported cases.

Angiotensin-converting enzyme inhibitors: synthesis and biological activity of N-substituted tripeptide inhibitors

A new series of highly potent angiotensin-converting enzyme (ACE) inhibitors, 1-(N2-substituted L-lysyl-gamma-D-glutamyl)octahydro-1H-indole-2-carboxylic acids, was synthesized; various acyl groups were introduced at the alpha-amino group of the N-terminal P1 Lys. The effect of the N2-acyl groups on in vitro inhibitory activity and oral antihypertensive effect was examined. All of the synthesized N-acyl tripeptides were found to have in vitro inhibitory activity at an approximately nanomolar level, and showed antihypertensive potency in renal hypertensive rats at a dose of 10 mg/kg, when administered orally. Among them, compounds 7e, g and 9f, i, m showed potent and long-lasting antihypertensive effects compared with enalapril (2a). Their structure-activity relationships are also discussed.

Angiotensin-converting enzyme inhibitors: synthesis and structure-activity relationships of potent N-benzyloxycarbonyl tripeptide inhibitors

A new series of gamma-D-Glu-containing N-benzyloxycarbonyl (Z) tripeptide inhibitors of angiotensin-converting enzyme (ACE) was synthesized. The effect of varying the antepenultimate amino acid residue in this series on the biological activity was studied. Introduction of Lys and Orn residues at the P1 position provided the most potent inhibitors, 25a and 25b (IC50: 3.5 and 4.9 x 10(-9) M, respectively), which exhibited an oral antihypertensive activity. This result suggests that basic amino acid residues at the P1 position play an important role in binding with the S1 subsite of ACE in this series. Oral antihypertensive activity of selected compounds was evaluated.

[Acute and chronic effects of bunazosin in patients with congestive heart failure]

The acute hemodynamic effect (right atrial pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac index, heart rate, blood pressure) and neurohumoral response (alpha-ANP, plasma renin activity, aldosterone, angiotensin II) of Bunazosin, oral alpha 1 blocker, was investigated in 28 patients with congestive heart failure at rest and immediately after exercise. Bunazosin reduced alpha-ANP, but, other neurohumoral factors did not change. Bunazosin produced significant hemodynamic improvements both at rest and after exercise. Its chronic effect was also investigated in 11 patients in 28 days after taking oral Bunazosin. Improvement of hemodynamics at acute phase was also preserved at chronic phase without deterioration of neurohumoral factors. It is concluded that Bunazosin may be an effective Balanced vasodilator both at acute and chronic phases in patients with congestive heart failure.

[Pulmonary hypertension due to glycogen storage disease type II (Pompe's disease): a case report]

A rare case of pulmonary hypertension due to glycogen storage disease type II (Pompe's disease) was reported. An 18-year-old girl was admitted to Kawasaki Medical School Hospital because of cyanosis, dyspnea on exertion and amenorrhea. She was 149 cm in height and 29 kg in body weight. Clinical examination revealed that pulmonary artery pulse and right ventricular heave were palpable over the precordium. On auscultation, an accentuated pulmonic second heart sound, pulmonic ejection sound and diastolic decrescendo murmur (Levine III/VI) were heard in the second intercostal space at the right sternal border. Her skeletal muscles, especially her intercostal muscles were generally weak and atrophic. Her electrocardiogram showed a pulmonary P-wave and right ventricular hypertrophy. The chest X-ray revealed right ventricular enlargement and a dilated pulmonary trunk. On echocardiography, the right ventricle and the main pulmonary artery were dilated, and a systolic notch of the pulmonary valve was found. Swan-Ganz catheterization disclosed that pulmonary artery pressure, right ventricular pressure and mean pulmonary capillary wedge pressure were 76/35 (50) mmHg, 76/12 mmHg and 10 mmHg, respectively. Respiratory function tests showed severe restrictive ventilatory impairment with hypercapnea and hypoxemia. On biopsy of the left quadriceps femoris muscle, the most striking finding was numerous intracytoplasmic vacuoles. The small vacuoles were stained with PAS and acid phosphatase. Electron microscopy showed massive glycogen accumulation in the sarcoplasm and membrane bound vacuoles (glycogenosome). Alpha-1, 4-glucosidase activity in the peripheral lymphocytes was definitely decreased. Her pulmonary hypertension resulted from respiratory muscular atrophy and alveolar hypoventilation caused by Pompe's disease.

[A marked Hegglin syndrome in pheochromocytoma]

A 46-year-old man was hospitalized with paroxysmal headache and chest discomfort. His blood pressure varied, occasionally being up to 300/160 mmHg. Cardiac examination revealed a decrescendo type of diastolic murmur (aortic regurgitation) and S4 gallop. Both blood and urine catecholamine levels were extremely high. Electrocardiogram and echocardiogram showed severe left ventricular hypertrophy pattern presenting hypertrophic cardiomyopathic changes. The phonocardiogram showed marked Hegglin syndrome (QT; 450 msec and QII; 310 msec). Right adrenal tumor, pheochromocytoma was found on the abdominal CT scanning and 131I-metaiodobenzylguanidine (MIBG). In the post-operative period, Hegglin syndrome was completely abolished (QT; 360 msec and QII; 345 msec,), and also electrocardiographic left ventricular hypertrophy pattern improved immediately after surgical removal of the pheochromocytoma.

Antihypertensive mechanism of alacepril. Effects of its metabolites on the peripheral sympathetic nervous system

To elucidate the antihypertensive mechanisms of alacepril (DU-1219), the drug itself and its metabolites, desacetylalacepril (DU-1227) and captopril, were examined both in vitro and in vivo for their effects on the sympathetic nerve which innervates the peripheral vessels. 1. In isolated perfused mesenteric preparations from spontaneously hypertensive rats (SHR, DU-1227 (10(-6)-10(-5) mol/l) attenuated dose-dependently the increases in perfusion pressure and in norepinephrine (NE) overflow which were induced by electrical stimulation of periarterial sympathetic nerves (15 Hz). Captopril (10(-6)-10(-5) mol/l) caused a similar attenuation, though to a lesser degree, of the perfusion pressure but did not inhibit the increase in NE overflow. 2. The sympatho-inhibitory effect of DU-1227 in the above experiment was shown to be caused by DU-1227 per se, since no captopril was detected in either the perfusate or tissues perfused with DU-1227. 3. In pithed SHR, alacepril (3 mg/kg) caused as potent an inhibitory effect as captopril (3 mg/kg) on the pressor response to the electrical sympathetic nerve stimulation (3 Hz) at an oral dose about half as that of captopril on the molar basis. The effect of alacepril tended to last longer than that of captopril. However, at higher oral dose levels, the inhibitory effect of alacepril (30 mg/kg) was of the similar extent to that of captopril (30 mg/kg). 4. In pithed SHR which had received bilateral nephrectomy 2 to 8 h previously, alacepril (30 mg/kg p.o.) significantly attenuated the vasopressor response induced by electrical stimulation (1-30 Hz) 1 and 3 h after administration.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical significance of electrocardiographic P-terminal force in V1 in patients with hypertrophic cardiomyopathy]

The clinical usefulness of P-terminal force in lead V1 (P-TF) was evaluated in 49 patients with hypertrophic cardiomyopathy. These 49 patients were categorized as 17 with an abnormal P-wave (P-TF greater than or equal to 3.0 msec.mV: group A) and 32 with a normal P-wave (P-TF less than 3.0 msec.mV: group B). Systolic blood pressure response (delta SBP) during the treadmill exercise test was significantly less in the group A than in the group B (delta SBP: 36 +/- 22 mmHg, 58 +/- 26 mmHg, respectively). Left atrial dimension measured from the M-mode echocardiogram was 37.8 +/- 5.0 mm in the group A and 31.0 +/- 5.2 mm in the group B. These differences were statistically significant (p less than 0.05). Left ventricular end-diastolic pressure averaged 19.5 +/- 7.9 mmHg in the group A and 13.5 +/- 4.0 mmHg in the group B (p less than 0.05). When comparing the group A and B, negative dp/dt / positive dp/dt of the group A was significantly less (0.69 +/- 0.14, 0.90 +/- 0.18, respectively) and the time constant T of the group A was significantly prolonged (86 +/- 30 msec, 56 +/- 10 msec, respectively). According to classifications of hypertrophic cardiomyopathy, all patients with the obstructive type had an abnormal P-wave. On the contrary, the majority of patients with apical hypertrophy had a normal P-wave.(ABSTRACT TRUNCATED AT 250 WORDS)

New electrocardiographic criteria for diagnosing right ventricular hypertrophy in mitral stenosis--comparison with the Bonner's and Mortara's criteria

New criteria for the diagnosis of right ventricular hypertrophy (RVH) using a point scoring system were developed after analyzing standard 12-lead ECGs in 155 patients with mitral stenosis verified by cardiac catheterization and 155 age and sex-matched apparently normal healthy subjects. ECGs were evaluated to identify criteria that provided maximum sensitivity and at least a 95% specificity: (1) the R wave magnitude in V1 had to be greater than 0.7 mV; (2) the S wave magnitude in V6 had to be greater than 0.3 mV; (3) the S wave magnitude in V1 less than 0.5 mV; (4) the R wave magnitude in V1 plus the S wave magnitude in V6 minus the S wave magnitude in V1 must be greater than 0 mV; and (5) the degree of frontal QRS axis had to be greater than 90 degrees. Application of these criteria achieved 25% (39 of 155) sensitivity in patients with RVH, significantly better (p less than 0.01) than the 17% sensitivity (17 of 155) of Bonner's criteria for the automated ECG. The specificity of the proposed criteria was 98% (152 of 155), significantly better (p less than 0.01) than the 90% specificity (139 of 155) of Mortara's criteria. Thus, it was evident that the accuracy of the proposed criteria was the highest among those criteria used in a point scoring system including the currently used automated ECG criteria for the diagnosis of RVH.

Right ventricular outflow obstruction secondary to post-infarction aneurysm: a possible new syndrome

Two patients with extensive anterior myocardial infarction developed a hitherto unreported type of right ventricular outflow tract obstruction. A 71-year-old woman, who had had an acute infarction 10 years before, was admitted for sustained ventricular tachycardia. A loud ejection murmur was heard in the mid-precordium. The echocardiogram and left ventriculogram showed a septal aneurysm, with a systolic gradient of 21 mmHg between the right ventricular outflow tract and apex. The ejection murmur was detected in the outflow tract by intracardiac phonocardiography. The second patient was a 60-year-old man who had had an acute infarction at age 47. He was also referred because of ventricular tachycardia, and his clinical situation was almost the same as that of the first case. Our search of the literature failed to disclose any similar case with a loud ejection murmur confirmed by intracardiac phonocardiography to be due to an obstructive septal aneurysm.

A new syndrome: angiotensin-converting enzyme dysfunction syndrome: differential diagnosis and pathogenesis--case reports

The authors previously reported a new syndrome, angiotensin-converting enzyme dysfunction syndrome (ACEDS), which is clinically characterized by mild systemic hypertension, a hypokalemic alkalosis, and hyperreninism with a high concentration of angiotensin-I (ANG-I), a normal angiotensin-II (ANG-II) value, and a normal aldosterone level. In the present study, they investigated the diagnosis and differentiation of diseases concomitant with hyperreninism, such as ACEDS, Bartter's syndrome, familial periodic paralysis, and renovascular hypertension treated with captopril for two months, and discussed the pathogenesis of ACEDS.